New Patient Intake Form - Dr. Ramita Verma

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Seymour Health Centre Hornby
1290 Hornby Street
2nd Floor - Station 1
Vancouver BC

Phone: 604-416-1899

Please note this is for setting up an initial consultation with a new provider. This does not indicate that the provider has taken you on as a patient. This is a consultation to ensure that you as the patient, and the provider are a good fit for one another for your ongoing healthcare needs.

Consultations are scheduled in order of applications received.

These consultations will be held either virtually or in-person. This will be at the providers discretion.

Email *

Who referred you to Dr. Ramita Verma? *

Your Full Name (and preferred name if different) *

Date of Birth *

YYYY

Age *

Phone Number (best number to reach you) *

Your COMPLETE Address (Please include your apartment number and postal code) *

Occupation *

Gender (Legal Sex at Birth) *

Male

Female

Other

Gender Identity *

Male

Female

Nonbinary

Transgender

Preferred Pronouns

Do you currently have a GP? *

Yes

If yes, why do you wish to transfer care?

Please list any medical problems other doctors have diagnosed (past, chronic, ongoing) *

Please list any surgeries you've received. Have you been admitted to the hospital in the last year? If so, for what reason? *

Please list your family history of medical problems (including parents sets of grandparents and siblings) *

Allergies *

Please list your most concerning health issues at this time *

Over the past 12 months, have you seen a doctor and if so, for what concerns? *

Do you see any other specialists or doctors routinely? *

Yes

Do you currently have any medical/legal, ICBC, WorkSafe or other issues we should be aware of? *

Yes

If yes, please describe

Is there anything else you would like us to know about your health? If yes, please explain:

Females between age 50-74 are recommended to have a mammogram every 2 years. If this applies to you, when was your last mammogram?

All adults between age 50-74 are recommended to have colon cancer screening. If this applies to you, when was your last colon cancer screen (i.e. at home poop test or colonoscopy)?

Females between age 25-69 are recommended to have pap smears every 3 years. If this applies to you, when was your last pap smear?

Do you have any dependents or a spouse/partner you are hoping to attach to the same family physician? Please list their names, ages and a brief medical history below.

Risks of Using Electronic Communication - I understand that the use of electronic communication such as this form, as well as email and phone calls can increase the risk of such information being disclosed to third parties. Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information. Electronic communications can be forewarded, intercepted, circulated, stored or even changed without the knowledge or permission of the patient or the physician. To minimize risk, limit using any third party computer when discussing medical information and inform the clinic of any changes in your email, phone number or address.
*

Yes

Appointments

For all appointments, including the initial consultation, please arrive 10 minutes early to your scheduled appointment, whether the appointment is held virtually, telephonically, or in-person, in order to guarantee being seen.

Missed Appointments

To become a patient of Seymour Health Centre and Dr. Ramita Verma's practice, it is required you consent to the following clinic policies regarding missed and/or late cancelled appointments.

I consent to Seymour Health Centre’s no-show policy and will be charged $89.70 if I do not show up for an appointment.
*

Yes

I consent to Seymour Health Centre’s late cancellation policy (< 24 hours notice) and will be charged $89.70 if I cancel within 24 hours.
*

Yes

I consent to a PharmaNet search by Dr. Ramita Verma at Seymour Health Centre when deemed necessary. PharmaNet is a province-wide network that links all pharmacies in B.C. to a central data system. For more information on PharmaNet: https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/pharmanet
*

Yes

Communications

While the provider will attempt to respond to all telephonic and electronic messages within 1-2 business days, please allow up to 72 hours for a response. For urgent care needs, please visit our Urgent Care Centre - open 7 days a week, 365 days of the year.

Forms

Any forms requiring completion by the provider should be submitted at least 1 week in advance. Whenever possible, early submission of the form(s) is highly recommended, if you wish to have completed in a timely manner.

Please type your name in the box below:

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